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HomeMy WebLinkAbout0043 TOMAHAWK DRIVE - Health 43 Tomahawk Drive Centerville P A = 190 018 0%,ford., NO. 1521/3 ORA 10% � s I h�. Commonwealth of Massachusetts 90- O/g Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 43 Tomahawk Drive, Centerville M - 190 P- 18 Property Address Margaret Gagnon Owner Owner's Name information is 43 Tomahawk Drive, Centerville MA 02632 Aril 7, 2020 #+required for every p page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms S'A. Inspector Information �-w on the computer, use only the tab Troy Williams key to move your Name of Inspector cursor-do not Troy Williams Septic Inspections use the return Company Name key. 19 Hummel Drive Company Address South Dennis MA 02660 City/Town State Zip Code (508) 385 - 1300 S1682 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails April 7, 2020 Inspector's Signatur Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �V 43 Tomahawk Drive, Centerville M - 190 P- 18 Property Address Margaret Gagnon Owner Owner's Name information is required for every 43 Tomahawk Drive, Centerville MA 02632 April 7, 2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System meets minimum standards set by Massachusetts DEP at the time of inspection only.This inspection is not a guarantee or warranty on the future working conditions of leaching, pipes, components or the future structural integrity of said components and only represents conditions found at the time of inspection only. 2) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 43 Tomahawk Drive, Centerville M - 190 P- 18 Property Address Margaret Gagnon Owner Owner's Name information is required for every 43 Tomahawk Drive Centerville MA 02632 April 7, 2020 page. CitylTown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ brokenpipe(s) are replaced Y p N ND Exl "❑ ❑ ❑ (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ,i� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 43 Tomahawk Drive, Centerville M - 190 P- 18 Property Address Margaret Gagnon Owner Owner's Name information is 43 Tomahawk Drive, Centerville MA 02632 Aril 7 2020 required for every p page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 c � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 43 Tomahawk Drive, Centerville M - 190 P- 18 Property Address Margaret Gagnon Owner Owner's Name information is 43 Tomahawk Drive, Centerville MA 02632 Aril 7 2020 required for every p page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® , Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or ❑ ® tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 e Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 43 Tomahawk Drive, Centerville M - 190 P- 18 Property Address Margaret Gagnon Owner Owner's Name information is required for every 43 Tomahawk Drive, Centerville MA 02632 April 7, 2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. Determined in the field (if any of the failure criteria related to Part C is at issue ® ❑ approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 43 Tomahawk Drive, Centerville M - 190 P - 18 Property Address Margaret Gagnon Owner Owner's Name information is required for every 43 Tomahawk Drive, Centerville MA 02632 April 7, 2020 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 gpd Description: 4 bedroom design per info given to me by BOH. Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: N/A Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage N/A 9 ( Y 9 (gpd)) Detail: Sump pump? ❑ Yes ® No Last date of occupancy: occasional use Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments l 43 Tomahawk Drive, Centerville M - 190 P - 18 Property Address Margaret Gagnon Owner Owner's Name information is 43 Tomahawk Drive, Centerville MA 02632 April 7 2020 required for every P page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions:, Type of Establishment: N/A Design flow(based on 310 CMR 15.203): N/A Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): N/A Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: N/A Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water mete rre adings, If available. N/A Last date of occupancy/use: N/A Date Other(describe below): N/A 3. Pumping Records: Source of information: Last pumped in 2016 per info from owner. Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 43 Tomahawk Drive, Centerville M - 190 P- 18 Property Address Margaret Gagnon Owner Owner's Name information is 43 Tomahawk Drive, Centerville MA 02632 Aril 7 2020 required for every p , page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Tank, d-box and leaching were installed approx. 9/28/96 per permit. Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 18" Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Lines were found clear at the time of inspection. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 43 Tomahawk Drive, Centerville M - 190 P- 18 Property Address Margaret Gagnon Owner Owner's Name information is required for every 43 Tomahawk Drive, Centerville MA 02632 April 7, 2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 2'with riser to 1' feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 6'X10.5'X6' 1500 gallon Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle 2' 8" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? probe/measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pvc inlet and outlet tees were found present and in working order. No evidence of leakage or damage was found. Working level in tank is a little above inlet invert. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 o Commonwealth of Massachusetts p Title 5 Official Inspection Form 11. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 43 Tomahawk Drive, Centerville M - 190 P- 18 Property Address Margaret Gagnon Owner Owner's Name information is 43 Tomahawk Drive, Centerville MA 02632 April 7 2020 required for every p page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: N/A feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: N/A Scum thickness N/A Distance from top of scum to top of outlet tee or baffle N/A Distance from bottom of scum to bottom of outlet tee or baffle N/A Date of last pumping: N/A Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): N/A 8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: N/A Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: N/A Capacity: N/A gallons Design Flow: N/A gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I4 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments !% 43 Tomahawk Drive, Centerville M - 190 P- 18 Property Address Margaret Gagnon Owner Owner's Name information is required for every 43 Tomahawk Drive, Centerville MA 02632 April 7, 2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: N/A Alarm in working order: ❑ Yes ❑ No Date of last pumping: N/A Date Comments (condition of alarm and float switches, etc.): N/A "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert level Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box was found level and in working order. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts I�. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 43 Tomahawk Drive, Centerville M - 190 P- 18 Property Address Margaret Gagnon Owner Owner's Name information is 43 Tomahawk Drive, Centerville MA 02632 Aril 7 2020 required for every p page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No` Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): N/A " If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 4 infiltrators withstone ❑ leaching galleries number: 34'X 11'X2' ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5 insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form io Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 43 Tomahawk Drive, Centerville M - 190 P- 18 Property Address Margaret Gagnon Owner Owner's Name information is required for every 43 Tomahawk Drive, Centerville MA 02632 April 7, 2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil was sandy. Chambers were dry at the time of inspection. Dug and checked stone and found dry and clean. No evidence of hydraulic failure or problems in the past were found at the time of inspection. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration N/A Depth —top of liquid to inlet invert N/A Depth of solids layer N/A Depth of scum layer N/A Dimensions of cesspool N/A Materials of construction N/A Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 �C\ Commonwealth of Massachusetts - Title 5 Official Inspection Form ie Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 43 Tomahawk Drive, Centerville M - 190 P- 18 Property Address Margaret Gagnon Owner Owner's Name information is 43 Tomahawk Drive, Centerville MA _ 02632 Aril 7 2020 required for every p , page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: N/A Dimensions N/A Depth of solids N/A Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 c ' Commonwealth of Massachusetts Title 5 Official Inspection Form �n Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 43 Tomahawk Drive, Centerville M - 190 P- 18 Property Address Margaret Gagnon Owner Owner's Name information is 43 Tomahawk Drive, Centerville MA 02632 April 7, 2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately aGtl�k,. 'J �k-- � I 1 I I 9 - 301 �, - 'ills , ® 3 5v1 3 - 57► S 73' a t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 43 Tomahawk Drive, Centerville M - 190 P - 18 Property Address Margaret Gagnon Owner Owner's Name information is 43 Tomahawk Drive, Centerville MA 02632 Aril 7 2020 required for every p page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 10.0'+feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ® Accessed USGS database-explain: SDW 252 Zone D 46.8' 2.3' adjustment/MIW 29 Zone D 6.5' 1.3' adjustment You must describe how you established the high ground water elevation: Hand augered 4.5' below bottom of leaching with no water found at a depth of 7.0'. Groundwater adjustment at the time of inspection was 2.3'/ 1.3'. Bottom of leaching at 2.5'was found not to be located in the high groundwater elevation at the time of inspection. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title -5 Official Inspection Form io Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 43 Tomahawk Drive, Centerville M - 190 P- 18 Property Address Margaret Gagnon Owner Owner's Name information is 43 Tomahawk Drive, Centerville MA 02632 Aril 7 2020 required for every p page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 C, r TOWN OF BARNSTABLE LOCATION 3 V0 SEWAGE # i VILLAGE eee?� Illlf� ASSESSOR'S MAP&LOT ~INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY �d LEACHING FACILITY: (type) L �ti / A b (size) I-v NO.OF BEDROOMS BUILDER OR OWNER .�/'1�� ���s©h ��'• PERMITDATE: q—Z,5'—�71� COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by r No. �-` Vf� eec-�� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ZppYtcatton for Mi5paar *pttem Comaructton Vermtt Application is hereby made for a Permit to Construct( )or Repair(v)an On-site Sewage Disposal System at: Location Address or Lqt N_ o. a� � � a �j Opwner' Name,Address and Tel.No. InsJr//�,al©le'ss N�a �A �ss,ands �No. 77�_Q�/J� Designer's Name,Address and Tel.No. /vG � ✓ s z i Type of Building: Dwelling No.of Bedrooms Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Description of Soil Nature of Repairs r Alterations(Answer when applicable) P-AOX Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by Bo of al _ Signed Date X VC/W Application Approved by Application Disapproved for the following reasons Permit No. �' IJ Date Issued r � - g No. Zee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS ZippYication for Mioogat *pgtem Congtruction_vermit S Application is hereby made for a Permit to Construct( )or Repair(�-4an On-site Sewage Disposal System at: Location Address or L t No. Owner's Name,Address and Tel.No. Ins aller's N e,A dress,and Tel.No. �7�_. d�+/� Designer's Name,Address and Tel.No. qr Type of Building: Dwelling No.of Bedrooms Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Description of Soil Nature of Repairs rAlterations(Answer when applicable) ;.-�.. !�- e v S ol a i ) ✓`¢fir.-S k//th s�© beg ep�­ Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-'� cate of Compliance has been issued by Bo of al Signed Date �!( Application Approved by Application Disapproved for the following reasons Permit No. 7 o '-"VI? Oro Date Issued --------------------------- THE COMMONWEALTH OF MASSACHUSETTS l PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Certificate of Compliance THIS IS TO CF�TIFY,thas the On-sit ewage Disposal System installed( )or repaired/replaced(� )on by (1e f ra,10 ` G AX!5V or as 4/ �D�i'�/f� // has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. r' ' dated Use of this system is conditioned on compliance with the provisions set forth below: l • � No. ` /�i �v 0 Fee e �. THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE. MASSACHUSETTS Migoar *p/ztem C/o1 n!5truction Vermit Permission is hereby granted to ,too/" to construct( )repair( ✓)an On-site Sewage System located at 4/ 72P we?f1Aly.� and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction must be completed within two years of the date below. ^^ Date: Approved ---! CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION I'EIM1I T (WITI10U-I' DESIGNED PLANSI hereby certify that the application for disposal works construction permit signed by me dated concerning the property located at 1/3 r1ax—If �,� ��e meets all of the following criteria: ✓ Thcre are no wcltands within 300 rector the proposed septic system /Thcre are no private wells within 150 reel of the proposed septic system I is observed groundwater table is 14 feet or greater below the bottom orthe leaching facility ��ere is no increase in flow and/or change in use proposed Tbcre are no variances requested or needed. SIGNED: DA•1B• LICENSED SEPTI SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan or the proposed system. Also irthe licensed Installer posesses a certHied plot plan, this plan should be submitted]. 1 s� I 7u MA-Ba.4tJA J I- �/a T.cfnAHAW k ., . • '" /TOWN�0 BARNSTABLE ll LOCATION °� `�� SEWAGE #Z . 0t�i� � �� �. �s5 VILLAGE ASSESSOR'S MAP & LOT j INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) s Ct4 '440.0 BEDROOMS BUILDER OR OWNER �,4 l'iy PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 fe�f:'f leachin f ility Feet Furnished by r r4 61 DATE: 2./.1..7./,96 PROPERTY ADDRESS: � � 7`6-mahawk Dri vP , ASSESSORS M HO; Centerville,Mass pARCO.Na f $' '02632 , lb s On the above date, 1 Inspected the septic system at the above a ��bess. This system consists of the following: pcf 1 . 2-61x81, block cesspools and 1 -1000 gallon leaching pit°:'_ Fe v 2. 1 main cesspool with one cesspool left as an overflow and al!gy � 1g leaching pit right as an overflow. 3 . Main cesspool acts as a septic tank. Based on my Ins action, I certify the following conditions: 1 . This is not a title five septic. sys.tem. 2. Tha,e- is' a sewage. system. 3 . The system is in failure and must. be. .upgr.aded to:;;,a title five septic system. - a, f SIGNATURr': t9fdlL ` �a Name: J_P_M_acomber Jr.. ; i . Company:- -P.Macon)ber & Son- *Inc .. ; Address:_-Be�c_bb-----= ----.-- Cente!rvi11eLMass__02.632 ' SSES50 t _- ASfiQAPN� �T:<� Phone:---548�Z7-5�3338 '- ► PARC..tLN0: - THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY LJOSEPHL- .� ER & SON, INC.Leschfleld:nstslied onnectlons le, MA 02632-0066 75-6412 .D Commonweatth of Massachusetts Executive Office of Envlronmental Affairs Department of Environmental Protection William F.Weld Trudy Cox* A g�r Paul Celluccl 8"y David B.Struhs e commfs.lawr e SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 43 Tomahawk Drive Centerville MassAddressofowner. Date of Inspection:2/16/9 6 (If different) Name Oflnspector..Joseph P. Macomber Jr. Company Name,Address and Telephone Number. J.P. Macomber & Son Inc . Box 66 Centerville ,Mass . 02632 508-775-3338 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: _ Passes — Conditionally Passes —.,,Needs Further Evaluation By the Local Approving Authority _Y_ Fails Inspector's Signature: Date: o�!9,96 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY- Check A,B,C,or D: A) SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. BJ SYSTEM CONDITIONALLY PASSES: NO One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indicate7as,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain wily not) /PP&, The septic tank is metal,cracked,structurally unsound,shows substantial infiltration or exilltration,.or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 11/03/95) 1 One Winter Street a Boston,Massachusetts 02108 a FAX(617)SWID49 • Telephone(617)292-SM e, Printed on Recycled Paper SUBSURFACE SEWAGJ&DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(oontinued) Property Address: 43 Tomahawk Drive Centerville ,Mass . 02632 Owner. John Haley Date of Inspection: 2/16/9 6 Bj SYSTEM CONDITIONALLY PASSES(continued) i(10 dU K Sewage backup or breakout or BA static water level observed in the distribution boat is due to broken or obstructed pipe(o) or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed Cl FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: A/Q Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: jj) Cesspool or privy is within 50 feet of a surface water A,V Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. �!Q The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. I The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. 3) OTHER (revised 11/03/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(oontinued) Property Address: 43 Tomahawk Drive Centerville ,Mass . 02632 Owner. John Haley Date of Inspection: 2/1 6/9 6 D) SYSTEM FAILS: s e I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. A,0 i9ok Static liquid level in the distribution bar above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than L2 day flow. q P AD Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of tunes pumped QD Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. d0 Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Q Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: 4119 The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: lI the system is within 400 feet of a surface drii] water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMIt 5.00 and 6.00. Please consult the local regional office of the Department for fluther information.. (revised 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST PropertyAddrew 43 Tomahawk Drive Centerville,Mass . 02632 Owner. John Haley ee Date of Inspection: 2/1 6/9 6 Check if the following have been done: ` Pumping information was requested of the owner,occupant,and Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal now rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. -L/As built plans have been obtained and examined. Note if they are not available with N/A ,�—/The facility or dwelling was inspected for signs of sewage back-up. 2The system does not receive non-sanitary or industrial waste flow , The site was inspected for signs of breakout. All system components,alluding the Soil Absorption System,have been located on the site. A,,c 7;�V4 The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baMes or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. zThs facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/03/95) 4 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION PropertyAddresw 43 Tomahawk Drive Centerville ,Mass . Owner. John Haley Date of Inspection: 2/16/9 6 FLOW CONDITIONS RESIDENTIAL, • Design flow ' ___gallons • Number of bedrooms:, Number of current residents:,- Garbage grinder(yes or no):,'82$ Laundry connected to system(yes or no):AL& Seasonal use(yes or no):_ Water meter readings,if available: = n s Last date of occupancy.�'7 COMMERCIAL/INDUSTRIAL:- Type of establishment: Design flow: A)19 ,gallons/day Grease trap present:(yes or no)AR Industrial Waste Holding Tank present: (yes or no)_A2g Non-sanitary waste discharged to the Title 5 system: (yea or no)A Water meter readings,if available: NO Last date of occupancy: OTHER(Describe)_ A) Last date of occupancy: GENERAL INFORMATION PUMPING and source of information: System (�pumped as part of inspection: (yes or no) If yes,volume pumped: o Reason for pumping TP..� i&"/ TYPE OF SYSTEM ills Septic tanVdistribution box/soil absorption system Single cesspool Overflow cesspool Privy 2� Shared system(yes or no) (if yes ttach previous' pectio records,if any) Other(explain)_ _ ^���d /" _/U &'q � /7, PRO TE AGE of all components',ante installed(if known)and source of information: 1; 4i y it Sewage odors detected when arriving at the site: (yes or no)620 (revised 11/03/95) 6 io SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) Property Address: 43 Tomahawk Drive Centerville ,Mass . Owner. John Haley Date of Inspection: 2/16/9 6 � a . . SEPTIC TANK 4V e, s (locate on site plan) Depth below grade:J Material of construction: ncrete metal_FRP_other(explain) Dimensions: Sludge depth: 4/* Distance from top of sludge to bottom of outlet tee or baffle: AS, Scum thickness: A)l� Distance from top of scum to top of outlet tee or baffle:_NA_ Distance from bottom of scum to bottom of outlet tee or battle: /VA Comments: (reoommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.)- Veej, ea'at 0f,4 /T ci GREASE TRAP: 4,le, (locate on site plan) Depth below grade:A)* Material of conatruction� _ ooncrete_metal_FRP other explain) Dimensions• V Scum thickness: A Distance from top of scum to top of outlet tee or baffle:—aa Distance from bottom of scum to bottom of outlet tee or baffler Comments: (recommendation for pumpmig,CODAtion of inlet and outlet tees or bames,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.). 6 �rl'1 riJ Pa(TI"S (revised k1/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) Property Address: 43 Tomahawk Drive Centerville,Mass . Owner. John Haley Date of Inspeotion: 2/16 9 6 TIGHT OR HOLDING TANX:&•yG • (locate an site plan) Depth below grade: LIAI. . Material of construction: ncrete_metal FRP_other(explain) - Dimensions: IV4 Capacity: 109 eallons Design flow: Alarm level: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) AJ a Cd�-rtvc�E�r(JYS . DISTRIBUTI X:ON BO IAA (locate on site plan) Depth of liquid level above outlet invert:_ Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) PUMP CHAMBER44we— (locate on ate plan) Pumps in working order:(yes or no) if/4 Comments: (note cond4oipn of pump chamber,condition of pumps and appurtenances,etc.) /too C:o wt wl$ayYS (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) PropertyAddress: 43 Tomahawk Drive Centerville ,Mass . Owner. John Haley Date of Inspection: 2/1 6/9 6 SOIL ABSORPTION SYSTEM(&AS)qt4i�8'�2 9���sy 1AAC J r1"' (locate on site plan,if possible;excavation not requir=d,but may be approximaW by non-intrusive methods) If not determined to be present,explain: e Type: leaching pits,number. leaching chambers, leaching galleries,number. leaching trenches,number,length: Q leaching fields,number,dimensions: overflow cesspool,number:__,__ Comments: (note condition of soil,signs of hydraulic failure,level of po dam,co n of vegeta ' n,etc.) Loam sand to sand & ravel•Yes gron-d 61ack around ce , ndind Water is above inlet outlet i es in the cesspoo , --standing water over inlet pile to leaching pit•Water standing in coiiar on the 1 aching pit. CESSPOOLS: (locate on site plan) Number and configuration: Depth-top of liquid to' t invert , Depth of solids layer Depth of scum layer. 91 Dimensions of cesspool: Materials of oonstruction: Indication of groundwater: inflow(cesspool must be pumped as part of inspection) l n ,:, %� ',04 _ �V ST.n 104L S Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) Same as above PRIVY: (locate on site plan) Material-of construction• mil} Dimensions• y4? Depth of solids: A W Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) (revised 11/03/95)� 8 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) ProP°rtYAddress;- 43 Tomahawk Drive Centerville ,Mass . Owner. John Haley Date of Inspection: 2/1 6/9 6 e SKETCH OF SEWAGE DISPOSAL SYSTEM: e include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' �lvK �7C.r �D�11/f'J� _7 i f K '0" � �F �G • o,. G Q DEPTH To GROUNDWATER Depth to groundwater.-!A�feet method of determination or approximation: Instal 1 e d Leaching pit 9/14/8 3 permit # 8 3-6 8 3 rn wAter encountered at tweive lee . (revised 11/03/95) 9 e. IH �•.mn}lrTR1'R�TT�lT1r.�t19f'RTiTtii"RI:�Rf.!'RR::TT'Rrl'RT•ti�'irr'11fST..Ti tvi:'C7lr R`, 7'7T'1'Tr�.•Ii�fTr••..�,•.f�•• TOWN OF Barnstable BOARD OF HEALTH SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION �/ (<•••rr•sir•••:: --.Trr.-.arrsmrm•n:rrrr.rams.rav-rrrr�+-rrrrs+rra:rmar�+rnc.raersrmnrsrna�rrs e.mn�mr+rrssv+err..rr+.n•.r:rrr•r.•-rr•-r• -TYPE OR PRINT CI.EARLI'- PROPERTY INSPECTED STREET ADDRESS 43 Tomahawk Drive Centerville ,Mass . ASSESSORS MAP, BLOCK MD PARCEL # /. qd—A l- • OWNER' s NAME John Hale .I PART D - CERTIFICATION NAME OF INSPECTOR Joseph P. Macomber Jr.. COMPANY NAME J.P.Macomber & Son Inc . COMPANY ADDRESS Box 66 Centerville ,Mass . 02632 Street Town or City state LIP COMPANY TELEPHONE (�08 ) 775 - 3�38 FAX ( 508 790 1578 Rirnsn•ea�•a•r.rn nT CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposil system at this address and that the information reported is true , accurate, and complete as of the time of .-inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one: r : System PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15. 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. , 'System FAILED* The inspection which I have conducted has found that the system fails to protect the public health and. the environment in accordance with Title 5 , 310 CMR 15 . 303., and as specifically noted on PART C - FAILURE CRITERIA of this inspection form. 4 ' Inspector Signature IYA id 5 ev j Date 2/17/96 ' % One copy of this certification must be provided to the OWNER, 'the BUYER ( where applicable ) and the BOARD OF HEALTH. * If the inspection FAILED, the owner or"'o orator shall u P p pgrAde ' the system within one year of the date of the inspection, unless allowed or required otherwise as provided in 310 CHR 15 , 305 . C. 1 r TIRE COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF ENVIRONYiENTAL .PROTECTION BE IT KNOWN THAT Joseph P. Macomber, Jr. • • • i Has satisfied ythe..Department's qualifications.as required and.-is hereby authorized to use the title CERTIFIED TITLE 5 SYSTEM INSPECTOR as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the General Laws. Issued by The Department of Environmental Protection. June S. 1995 r Acting Director of the • ion of Water Pollution Control I I � _. . No. 7ee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppCication for Die;p&W *potem Con!gtruction Permit Application is hereby made for a Permit to Construct( ::)or Repair(v)an On-site Sewage Disposal System at: Location Address or L t No. // ' ;p Name,Address and Tel No. Ins aller's Narp e,A djess,and Tel.No. 771_Q�QQ Designer's Name,Address and Tel.No. Type of Building: Dwelling No. of Bedrooms Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Description of Soil Nature of Repairs gr Alterations(Answer when applicable) o r� or-G y '. n ea o er f Q Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued byWBoof cai Signed Date Application Approved by Application Disapproved for the following reasons Permit No. Date Issued -- --------------=_=--_--._=—.r--THE COMMONWEALTH COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO C TIFY,tha1t the Op-sits ,Sewage Disposal System installed( )or repai red/rep]aced(P )on by Cl/OC 4 / C. GI9ST or as 413rOn G'/�' v has been construct d in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. �' dated Use of this system is conditioned on compliance.with the provisions set forth below: No. Fee THE.COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS ;hgpoal *potem Con$truction Permit Permission is hereby granted to O/ ����' � (- �e6 7. to construct( )repair an On-site Sewage System located at and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction must b_e completed within two years of the date below. Date: C/ �✓ s i d APProved by— "' , LO•CAwT10-N- SEWAGE PERMIT NO. YILLA�+GE (e� IMSTA LLER'S NAME i ADDRESS 8U1LDER ' OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED //",/ xj -4Z 0 6 fv�Ne5 N-C LAC. ATION SEWAf E PE`RR f FAD. VILLAGE I N S 7 A LItER'S NAME A ADDRESS UILDE N OR own ER -do HN ) c UATE PERMIT� 155UED DAT E COMPLIANCE ISSUED 9 -57J0- •' r_ �• „ .... t ' �- .. V / \ ����\ / / ; \ - � / �i � \ � � o � ® �-/ ._ :. �: , THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............MW.Z.9........OF........Ba, S✓ ................................ Xplifiration for Dhipoiial Worko Toautrurtion Urrmit Application is hereby made for a Permit to Construct or Repair A-)—an Individual Sewage Disposal Sys"/ t at, Z6)2 ­ . .......... --­-------------*------ .............. Laion AddressNo.1? ....... .............................................. Owne Address -----------""---------.........Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder Other—Type of Building ............................ No. of persons............................ Showers Cafeteria Otherfixtures ....................................................................................................................................................... Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 04 Septic Tank—Liquid capacity............gallons Length________________ Width._.___._._...._. Diameter..._..._______.. Depth_..__.___.__.... Disposal Trench—No. .................... Width____._._.._.__._._._ Total Length.._._..__.__._..____ Total leaching area....................sq. f t. > Seepage Pit No_____________ ______. Diameter_._.__.___-_.___._.. Depth below inlet___._______.___._.__ Total leaching area..................sq. f t. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by--------- ................................................................ Date........................................ Test Pit No. I................minutesperinch Depth of Test Pit.__...___.________.. Depth to ground water_.___......__.___._..... Test Pit No. 2................minutes per inch Depth of Test Pit__.__.___...______.. Depth to ground water.._.___.._..__.__.___-_- ........................ ............. ... . ..................................................................................... 0 Description of Soil........................ ........................................ .............................................. "41 U ........................................................................................................................................................................................................ ...................................................................................................................... ........................................7.................................. U Nature of Repairs or Alterations—Answer when applicable................ Z2_d.....9.�O.Z..,X0 ......................... ........................................................................................................................................................................................................ Agreeinent: The undersigned agrees to install the aforedescribed. Individual Sewage Disposal System in accordance with the provisions of TAITL LE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has hbeee .ssued by the b f liealth boar I Dyf o Signed._ 06 ... . .. ........ .........—.................. AM t Application Approved By______________ .. .... ....................... ......jg—f? ­Zyp------------- Date Application Disapproved for the following reasons:................................................................................................................ ......................................................................................................................................................................................................... Date PermitNo......................................................... Issued_...._....---------....----- Date ----------------------------- ------ THE COMMONWEALTH OF MASSACHUSETTS ti BOARD OF HEALTH ............ .OWn........0F..........1..,, ' ``, }. �- ......................... Appliration for Uiipoiittl Work.5 Tonitrnr#ion Vamit Application is hereby made for a Permit to Construct ( ) or Repair ( 4-)-an Individual Sewage Disposal System at; - ,�j Lo/ation,mAddress - •- --.....1:229 .)7..... ... '. - -• ----•• _ ...NO..................•---•••-•••.._.......... or '�, , , _.: �Owne .. Address........................................... Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms...........................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures -------------------------------------------••-------•-.•----•-••-••--•- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length---------------- Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area___-.._-__---_-_____sq. ft. Seepage Pit No---------------------.Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Lz Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ -----------------------•• . -----..¢_.......••------•••---- 0 Description of Soil.......................... � --��-�-'_�-�-�� - ----------------------............................................................... x U ........................................................:--------........--•-------•------.............-•----------------------.........----------------•-------.._.•.-...---•-...--•--•••--------_-_... W -------------------------------------------------------•--------------------------------------------------------------. -------------------------------- ... ................. U Nature of Repairs or Alterations—Answer when applicable...............1.:�10.42.6).....�&...... Z......._.-_....--.__. ---------------------------------------------------------------------------------------------•-------........----------------•------•---------•-....................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code-The undersigned further a rees not to place the system in operation until a Certificate of Compliance has bee ssued by the b3oara of health. Signed..... :.... Date Application Approved By............................--- ...... - _ . .................. .0�. ......... Application Disapproved for the following reasons:------•--••-----------------•-•--•--•--------------•--•-----.....------------•---------••-:.....----•........... .-•.....................•---........---•-•-----....-•••-•----•-•--••-•-••-----•----••------•--_-••-. Date PermitNo......................................................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ... #.!I .a i ..............OF........ ,>'s - k.......................... Trr#ifiratr of Tomplittnrr THI IS _.O CERTIFY That the Individual Sewage Disposal System constructed ( ) or Repaired by- a... R f�: f* Z, ' `� :. :,:�k°.rs. ............................................................. -----•.................................. Ins � � 1/�d1� ~� at__ / has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described m the application for Dislosal Works Construction Permit No........ _ ...... dated-............................................... , THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRU AS A GUARANTEE THAT THE SYSTEM IL UNCTION SATISFACTORY. DATE.I ..._._..11-- •----.......................................... Inspector _ ......---- --------•---.............._....--••--.......---........_....._......... 4., THE COMMONWEALTH OF MASSACHUSETTS BOARD 9F HEALTH No.......4!�Jal .......... .......OF...... ",�c�s••.--....... .................... FEAtoj�/�� E__.......__.ff.4>.... Disposal ftrks Tong#rnrtan rrntit Permission is hereby granted -�/<.. .... ...... to Construct t R an n lvi Sew e D' sa� �ystem � �` -/ __....at -1 1 /. . Street y as shown:on the application for Disposal Works Construction Permit No..................... Dated........................................ .� ----------------------- 1 � Board of Health DATE....................................... FORM 1255 A. M. SULKIN, INC., BOSTON-